My Brother S House Inc

My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)

Date of Service:

Caretaker(s) Relationship

Address:

Home Phone Work Phone______Other______

Youth & Family Services Worker_NA______Relationship______

Address ______

Office Phone ______Other Phone______Fax______

Present Living Situation

Name Relationship AGE/DOB ______

Available Resources for Client

Contact Name Phone Agency/Relationship 1. 2.______3.______4.______5.______

Chief Complaint

History of Present Illness (symptom onset, duration, precipitating events)

Risk Assessment Potential danger to self? yes no suicidal ideation plan recent attempt self-mutilation cruelty to animals witness to domestic violence yes no Describe:

Past danger to self? yes no past suicidal ideation past attempt fire setting cruelty to animals?

Describe any history:

Potential danger to others? yes no assaultive ideation plan attempt Describe history:

Access to firearms? yes no details______

Behavior Patterns:

Eating/Appetite: no problems weight increase/decrease of ___ lbs. in __weeks/months loss of appetite increased appetite food cravings laxative abuse skipping meals bingeing vomiting diuretic use compulsive exercising

Sleeping pattern: no change increased decreased difficulty falling asleep frequent awakenings sleeping during day nightmares/terrors sleep medication Self care: no problems Difficulty with: bathing dressing getting out of bed motivation/interest chores social interaction enuresis encopresis Page 2 My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax)

Energy: excessive energy lacks energy

Pain: Are you having pain now? yes no Are you being treated by your primary physician? yes no If no, therapist encouraged client to seek services of PCP? yes no

Significant Family History

Medical History Allergies: yes no type:

Reaction: yes no describe:______Operations and dates: Current medications:

Developmental Milestones

Do you have any concerns about your child’s growth? Any complications during pregnancy or delivery? Length of pregnancy? ___weeks birthweight_____ lbs. _____ oz. Age at which child: rolled over:_ ___ sat up:______crawled:______stood alone:_____ walked:______said single words:______2-word sentences______3-word sentences:______

Any concerns about motor skills (running, walking, writing, use of scissors)? Describe?______

Social History:

Recent family stressors/losses: History of abuse (current & past) none emotional physical sexual Describe:______

My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) Legal History: none training school/ detention probation past charges current charges

Mental Health Exam: Mood: appropriate euthymic depressed sad anxious irritable maniac euphoric blunted flat labile tearful Describe:______

Thought content: appropriate obsessions paranoia delusions preoccupation Describe:______

Thought process: slow normal circumstantial blocking tangential flight of ideas Hallucinations: none auditory visual olfactory tactile gustatory Orientation: Person: yes no Place: yes no Time: yes no Memory: Short term: intact impaired Long Term: intact impaired Judgment: good fair poor Insight: age appropriate limited poor Concentration: good fair poor Motor activity: appropriate for age agitated/hyperactive hypoactive

Substance Abuse History: Substance Quantity/Frequency Route of Administration Age at first use/How long ______

Past Psychiatric or Substance Abuse Treatment Facility/Provider Type Level input/output Year LOS Comments ______

Family History Name Relationship Alcohol Drugs Physical/Sex Abuse Mental Illness

Ethnic/Cultural/Spiritual Influences None ______Ethnic______Cultural______Spiritual______Sexuality______

Education: Highest level completed____ Currently in school_yes____ School_ language:_English______Able to read: ______Able to write: ______Can patient understand and follow directions?______Special services: Are there any barriers to remember? yes no describe:______

Formulation (supporting documentation for diagnosis): ______

Strength/Weaknesses: ______

My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) ______

Diagnostic Impression:

______

I agree that I participated in the assessment:

Client: ______Date: ______

Guardian: ______Date: ______

Clinician: ______Date: ______

My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) Revised 01/18/2015

MBH Inc. Individual Counseling Client: Record Number: Date: Medicaid Number: DIAGNOSIS(ES): Type: Principal (P) Both Principal & Primary (B) Primary (R) Additional (A) Axis Code Type Description

Supports/Strengths

Date Date

Preferences

Date Date

Problem(s) / Need(s)

Date Date

MBH Inc. Service Plan Client: Record Number: Medicaid Number: Date: Service(s)/Intervention(s) Responsible Person/Position Goal (including frequency)

Outpatient Individual and/or Therapist Family Treatment 2 – 4 times a month

Target Reviewed Status Justification for Continuation/Discontinuation of Goal: Date Date Code

Status Codes: N=New R=Revised O=Ongoing A=Achieved D=Discontinued Date: Service(s)/Intervention(s) Responsible Person/Position Goal (including frequency)

Outpatient Individual and/or Therapist Family Treatment 2 – 4 times a month

Target Reviewed Status Justification for Continuation/Discontinuation of Goal: Date Date Code

Status Codes: N=New R=Revised O=Ongoing A=Achieved D=Discontinued

My Brother’s House Inc. 4822 Albemarle Rd Suite 105 Charlotte, NC 28205 (704)532-4770 (704)532-4774 (Fax) SERVICE PLAN

Client: Record:

I had input in the treatment plan/I agree with this plan.

______Date: Staff Signature Date: Parent Signature